Question about giving O2

hypocaffeinemia, BSN, RN · Jul 26, 2009

Pt has dx of chronic lung disease. RR 50, HR 140 irreg, skin pale and cool, confused to person/place/time. Orders include O2 NC 4L/min, bedrest, soft diet, PFTs in the AM.
Correct sequence of action is:
1. Semi-fowler position
2. ask staff member to stay with pt
3. call MD
4. give O2 NC at 4L/min
Can someone help explain why i shouldn't give the O2 before calling the MD, even tho it's already ordered?

This is the picture of someone that needs to be intubated pronto. Forget the nasal cannula-- this is the point where you reach for the non-rebreather and make sure you have an ambu bag at the head of the bed as you will likely be using it soon.

This is why questions like these in nursing school are so silly. You may never understand or agree with the exact rationale.

I can only assume by "call MD" they mean "call an MD that's actually on campus and is proficient at emergent intubations", because paging some internal medicine attending that's at home or in an office somewhere isn't going to do you a lot of good.

xiongmao · Jul 26, 2009

thank u hypocaff!

loricatus · Jul 26, 2009

Technically, O2 is considerd a drug and would need a Dr. order to administer. Remember, I said technically.

Although it was ordered, the physician needs to be updated on the pt's condition to verify that the order still stands or needs to be changed.

hypocaffeinemia, BSN, RN · Jul 26, 2009

Technically, O2 is considerd a drug and would need a Dr. order to administer. Remember, I said technically.

Technically, most MD's prefer their patients kept alive. Only technically.

morte, LPN, LVN · Jul 26, 2009

these questions oft dont make any sense......so you should leave the patient with no supplemental o2 (agreed, it wont do much good) and call the doc......who is going to take how long to get there? argh

nkara, CNA · Jul 26, 2009

I give a patient O2 and I'm a CNA .. if the patient needs it. I just let the nurse know.

Music in My Heart · Jul 26, 2009

Of course you would administer the ordered oxygen before notifying the physician. You could rightfully expect an ass-chewing if you called the doc to report the patient deteriorating and you hadn't even complied with an existing order to give the O2.

Ask your instructor what is their reasoning. Theirs is the only opinion that counts for the moment.

Daytonite, BSN, RN · Jul 26, 2009

can someone help explain why i shouldn't give the o2 before calling the md, even though it's already ordered?

this patient has

chronic lung disease

. in the chronic lung diseases (emphysema, chronic bronchitis, chronic obstructive asthma or chronic bronchitis with emphysema) the airways become narrowed and air and mucus become trapped within them. each inspiration of air may allow more gasses to enter, but the problem is that carbon dioxide is not getting out because of narrowing in the bronchi due to spasming, mucous buildup or alveoli collapse. in a disease like emphysema the alveolar walls have been damaged or destroyed and cannot recoil after expansion so that many times the alveolar walls overdistend and over time rupture and enlarge decreasing the surface area available for the oxygen-carbon dioxide gas exchange to occur. in addition, the tiny terminal bronchioles leading to each alveoli can collapse trapping any air in the alveoli sacs so gas isn't going to be able to move in or out of some of the individual alveolar sacs. primarily, carbon dioxide will build up in the patient's system because it has no other way to exit. giving the patient a higher flow of oxygen at 4l without also helping the airway obstruction, clearing the mucous and assisting the physical breathing process is not going to do anything for the physiological problem which is the poor gas exchange.

putting the patient in a semi-fowler's position shifts the abdominal organs downward and away from the lungs giving them more room to expand and do their work. it also promotes diaphragmatic breathing. breathing from the diaphragm helps to reduce the respiratory rate and increase the air going into the alveoli upon inspiration. by increasing the amount of air going into the alveoli with normal respirations you will be promoting the dislodgment and expulsion of mucous that might be trapped there.

by having someone stay with the patient you are providing reassurance that help is available if needed.

call the md for medical treatment to assist in the treatment. bronchodilators, anticholinergics, mucolytics, corticosteroids and antibiotics are all potentials medications that may be necessary to assist the patient, but all require a physician's order.

allnurses Guide · Jul 31, 2009

Strongly agree - the "chronic lung disease" is what stood out to me too. Increased work of breathing in a chronic emphysema patient is not helped by adding O2 most of the time. Nor is intubation in a chronic lung patient necessarily a good idea.

hypocaffeinemia, BSN, RN · Jul 31, 2009

Strongly agree - the "chronic lung disease" is what stood out to me too. Increased work of breathing in a chronic emphysema patient is not helped by adding O2 most of the time. Nor is intubation in a chronic lung patient necessarily a good idea.

The patient in the scenario was very clearly severely hypoxic-- see the altered mental status with tachypnea and tachycardia. The chronic lung disease is relatively irrelevant in this acute situation. I don't care about O2 reducing their respiratory drive when their RR is 50. Intubation on this patient is necessary not only to maintain airway (look at the neuro status), but also to at least attempt some aveolar recruitment and get some full FiO2 100% breaths down.

The alternative to not intubating the patient in respiratory failure (regardless of chronic lung disease) is to start preparing your post-mortem kit.

As an aside, the "O2 decreases a COPDer's respiratory drive" may be popular wisdom, but it isn't supported by evidence nor should it take precedence over acute hypoxic issues. We can always control the patient's respiratory rate.

Daytonite, BSN, RN · Jul 31, 2009

The question being asked by the OP required the rationales for why the sequence of nursing actions was to

Semi-fowler position
ask staff member to stay with pt
call MD
give O2 NC at 4L/min

not debate the need for the type of medical intervention needed.